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4 <br /> A1ltech Petro Inc. ` <br /> 17759 Buttercup Circle, Sonora, CA 95370 <br /> Phone: 209-532-7320; Fax: 209-533-2650 <br /> California Contractor 623541 A-Haz <br /> alltechmaiW,me.com <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Village West Marina I Date of Testing: 4/30/09 <br /> Facility Address: 6649 Embarcadero Drive Stockton CA 95217 <br /> Facility Contact: Mike Spence Phone: 209-951-1551 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(i(present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Alltech Petro Inc. <br /> Technician Conducting Test: Isaac Anderson <br /> Credentials: ®CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type:A-Haz License Number: 623541 <br /> Manufacturer TraininL <br /> Manufacturer Component(s) Date Training Expires <br /> Caldwell Sump Tester 4-13-11 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 91 Turbine Sump 91 Fill Bcket ® ❑ ❑ ❑ <br /> Red Diesel Turbine Sum ® ❑ ❑ ❑ 91 Vapor Bucket ® ❑ ❑ ❑ <br /> Transition Sump Z . ❑ ❑ ❑ Red DSL Fill Bucket ® ❑ ❑ 1 ❑ <br /> UDC 1 ® I ❑ I ❑ ❑ I ❑ ❑ ❑ 1 ❑ <br /> UDC 2 ® ❑ 1 ❑ 187 Annular ® ❑ ❑ ❑ <br /> UDC 3 ZI Ell ❑ ❑ I Red DSL Annular ® ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 91 Product Line to transition ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Red Diesel Product Line to ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> transition <br /> 91 Product Line to dispensers ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Red Diesel Product Line to ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> dispensers <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tuts: <br /> Testing water stored in barrels onsite <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date:4/30/09 <br />